DROWNING AND NEAR-DROWNING Dr.Özgül Keskin Yeditepe University School of Medicine Department of Anesthesiology and Reanimation

It is one of Nature’s greatest ironies that man should spend the first nine months of his existence continously surrounded by water, but the rest of his life with an inherent fear of submersions B. A. GOODEN

USA; leading causes of death 0-4 years-old 6th 5-14 years-0ld 4th > 500 000 deaths/year due to drowning Mostly 5-14 years of age 4th frequent cause of death in the same age More frequent in pediatric age group Fresh water drowning > salt water drowning Especially in <5 y age group drowning in bathtubs are frequent Drowning affects healthy people in young and productive age group USA; leading causes of death 0-4 years-old 6th 5-14 years-0ld 4th

Statistical Risk Factors Age: Youth 40% under 4 years old Location: Pools, bathtubs, lakes, rivers Sex: Male 3:1 Time of year: Warm months

Definitions Drowning: Near-drowning: Drowning is defined as death resulting from suffocation within 24 hours of submersion in a liquid medium Near-drowning: Near-drowning, as survival of (even with severe medical thrapy) at least 24 hours after an episode of suffocation caused by submersion in a liquid medium

Definitions Dry-drowning: Wet-drowning: Secondary drowning: Due to a sudden immersion into water, largyngospasm leading to asphyxia resulting with alveoli without water Wet-drowning: Drowning due to water in the alveoli Secondary drowning: Any secondary disease (Heart disease, epilepsy, alcohol use etc) leading to loss of consciousness in water, thereby drowning

Definitions Immersion Syndrome: The immersion syndrome (also called the immediate disappearance syndrome) is syncope provoked by bradycardia, tachycardia, or arrhythmia precipitated by sudden contact with water at a temperature of at least 5°C less than body temperature. It can happen, therefore, in water as warm as 31°C

Chain of events Immersion in water Breath holding voluntarily and with panic Struggle of the victim Unvoluntarily point of cession (vazgeçme noktası) Aspiration of water and/or laryngospasm Cardiac arrest due to on-going hypoxia Hypoxic damage of brain Cytotoxic cerebral odema Increased intracranial pressure, decreased cerebral blood flow Herniation and death

Pulmonary hypertension Pathophysiology (Pulmonary) Immersion in water Breath holding Aspiration of water Laryngospasm Alveolar hypoxia & hypercapnia ARDS Surfactant loss Left ventricular afterload Pulmonary hypertension Pulmonary edema Systemic hypoxemia and hypercapnia Cardiac depression Asistoli

Fresh Water Aspiration Hypotonic pass into capillary easily Hemolysis Pulmonary surfactant dissolution Alveolar collaps Atelectasis V/Q mismatch HYPOXEMIA

pass into alveoli easily Salt Water Aspiration Salt water aspiration Water Hypotonic pass into alveoli easily Hemoconsantration Water in the alveoli HYPOXEMIA

Electrolyte imbalance Consequences of Aspiration 2.2 cc/kg Hypoxia 11 cc/kg Blood volume changes 22 cc/kg Electrolyte changes Average aspiration is only 2-4 cc/kg

Cold water has more survivors and WARM WATER drownings are different Cold water has more survivors

Submersion victims aren’t dead until they are WARM and DEAD

Drown not thyself to save a drowning man Treatment Drown not thyself to save a drowning man

Treatment Resuscitation in the setting of accident A-B-C should be applied Mouth –to-mouth breathing should be started in water No need for cardiac massage in water, loss of time Heimlich and Patric maneuvers (?) Subdiaphragmatic pressure may be effective for draining water from the lungs They may both aspirate and drink water in to stomach also. Pressure may cause more aspiration Manual and mechanical ventilation with ETT Standart CPR SpO2 should tried to be kept at 90%

Treatment in ER & ICU Respiratory System ETT and mechanical ventilation if needed Positive end expiratory pressure (PEEP) 4-6 cm H2O to 12-14 cmH2O Aim is to make SpO2 >90%, while keeping FiO2 < 50% NG tube

Treatment in ER & ICU Cardiovascular System Thermoregulation Fluid replacement with appropriate solution Inotropic support Treat hypoglycemia and hypocalcemia to treat mycardial depression Thermoregulation Wet clothes should be removed Especially in children heat loss is very fast Heat the patient slowly with blankets and light IV fluids should be heated to 36-40 ̊C O2 should be heated and humidified (HMEF-Heated humidifiers) Peritoneal or bladder lavage

Treatment in ER & ICU Neurological System GCS <8 or Conn-Barker class C1 or C2 should be intubated and mechanically ventilated GCS <3 or Conn-Barker class C4 patients should not be resuscitated Increased ICP leads to bad prognosis and can not be treated if occured

Prognosis Factors for good prognosis Factors for poor prognosis Duration of stay in water <5 min Immediate CPR CPR duration <10 min Spontaneous ECG rhytm on ER admission GCS >5 on ER admission Spontaneous movement and heathy brain stem function in 24 hours Factors for poor prognosis Duration of stay in water >10 min CPR start > 10 min Cardiotonic drug need on ER admission GCS <5 No spontaneous movement after 24 hours